Chapter 2 Contents of the Project
Chapter 2 Contents of the Project
2-1 Basic Concept of the Project
The purpose of this Project is to improve and revitalize each target facility and their capacities and establish a system to provide more effective care and services by providing basic medical equipment and conducting technical training for health workers. Shown below is an outline of the Project contents that have been confirmed by the authorities concerned, including those on the Surinamese side.
Table 2-1 An Overview of the Project
Project Design Matrix [Overall Objective] To improve mother-and-Child health in Suriname. [Project Objective] To enhance the medical services provided by the target medical facilities by upgrading the basic infrastructure of the facilities, including building facilities, medical equipment, human resources, skills, and administrative/financial systems. [Outcome of the Project] The target medical facilities will be installed with basic medical equipment. [Input] (1) Japanese side ･Procure medical equipment for the target medical facilities. ･Implement the Soft Component Program. (2) Surinamese side ･Renovate the buildings of the target clinics. ･Give technical training to the medical staff concerned. ･Strengthen the operational/maintenance system of the facilities and equipment. Commencement and Completion of the Project: This Project will officially commence at the beginning of the technical training of the relevant Surinamese personnel following the signing of the Exchange of Notes (E/N) by both Governments and end at the completion of the Japanese Assistance Project.
Table 2-2 Verifiable Indicators of 2 hospitals for the Project
Indices ‘sLands Hospital Nickerie Regional Hospital Baseline Target Baseline Target (1) Clinical Activities - Number of Delivery - - 254 300 - Number of Caesarean Operation 444 462 - - - Total Number of Prenatal Care Examination 12,069 14,500 670 800 (2) Medical Equipment (Number of Patients) - Ultrasound Diagnostic Equipment 4,993 6,000 1,522 1,800 - X-ray Diagnostic Equipment 3,235 3,500 4,092 4,500 Notes: 1. Operational status of equipment is expressed by the aggregate number of patients for whom the equipment was used. 2. Baselines are the actual records of 2002. 3. Targets are to be achieved two years after the handover of the medical equipment.
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Table 2-3 Verifiable Indicators of 5 clinics for the Project
Indices A B C D E BL TI BL TI BL TI BL TI BL TI (1) Clinical Activities - Number of Delivery 135 150 69 75 0 87 0 37 0 25 - Total Number of Prenatal Care Examination 262 400 252 400 596 700 143 300 92 200
(2) Medical Equipment (Number of Patients) - Ultrasound Diagnostic Equipment 0 200 0 200 0 350 0 150 0 100 - Electrocardiograph (ECG) 0 240 0 240 0 240 0 240 0 240 Keys: A: Wonoredjo Clinic, B: Lelydrop Clinic, C: Derde Rijweg Clinic, D: Tijgerkreek Clinic, E: Koewarasan Clinic BL: baseline, TI: target index Notes: 1. Operational status of equipment is expressed by the aggregate number of patients for whom the equipment was used. 2. Baselines are the actual records of 2002. 3. Targets are to be achieved two years after the handover of the medical equipment. Source) Tables 3-2 and 3-3 were created based on discussions with the personnel of the MOH and the target medical facilities.
2-2 Basic Design of the Requested Japanese Assistance
2-2-1 Design Policy Prior to formulating the basic design of the Project, the following policies were set up respecting surrounding conditions and related environment.
(1) Basic Policy Basic guidelines for the proposed Japanese Assistance Project are as follows: ・ The Project should be in line with the national development plan of the Surinamese Government for the health/medical sector.
・ The Project should be manageable within the framework of the Grant Aid system of Japan.
・ The Project should not duplicate the activities of other donor countries and organizations.
・ The target facilities must be engaged in medical activities that are contributing to mother-and-child health.
・ The medical equipment to be procured by this Project should be operated and maintained within the resources of the Surinamese side.
(2) Policy on Staff Training Program The Surinamese government is planning the staff-training program. Those are training sessions for general practitioners in the five (5) clinics in the areas of diagnostic and curative in delivery, pediatrics and laboratory services. Furthermore, Academic Hospital Paramaribo will train
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operation of ultrasound diagnostic equipment and laparoscope with diagnostic methods for ‘sLands Hospital and Nickerie Regional Hospital concerned, managed by the MOH. The selection of equipment shall be prepared with the consideration of above-mentioned activities by the Surinamese side.
(3) Policy on Facility Infrastructure The Surinamese government will undertake the renovation work of the target clinics. We, as a consultant, will provide guidance and specific technical specifications so that they will be able to renovate the facilities in the way most suitable for installing the equipment. Although the electric power supply in Suriname is relatively stable, installing automatic voltage regulators (AVR) should be considered for the equipment used in operating rooms and neonatal care, as the accuracy of such equipment can be affected by voltage fluctuation.
(4) Policy on Using Local Procurement and Local Representatives In Paramaribo, there are six dealerships of medical equipment manufacturers, of which three, namely, N.V. Elgawa, Harsons Meditech Inc., and Triangle, can provide after-sales maintenance services. Our hearing survey in Miami, U.S.A. revealed that American manufacturers were not keen on selling their products in Suriname because of the small market size and the absence of nonstop flight between the two countries. Home appliance shop owners in Paramaribo confirmed the above statement by saying that Dutch products had advantage over American products in terms of availability of technical follow-up services. Only a few American companies have agents in Miami to provide maintenance services for Surinamese customers, whereas the vast majority have set up dealerships in Caracas, Venezuela, to and from which traveling by air is much more convenient. As far as we have researched, five agents of Japanese medical equipment makers are situated in Venezuela (by end of June 2003). The existing equipment of the target facilities of this Project mostly consists of Dutch, German, Swedish, French, American, Japanese, and other third-country products. Regular beds, wooden cupboards to store medical instruments, and other such simple items, but no medical equipment, are manufactured locally. In view of the above, the equipment for this Project will be chosen preferentially from Japanese, European, or American products, for which after-sales services will be available from agents in Suriname or Venezuela.
(5) Policy on the Maintenance / Management Capability of the Implementing Agency In order to achieve the goals of the Project, it is necessary to have a system that enables the equipment procured by the Project to be utilized effectively. Due to differences in the functions of equipment, some equipment is used daily for diagnosis and treatment while others are used only in
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emergencies. However, all these types of equipment must be maintained to function properly all the time regardless of the frequency of usage.
As for the maintenance of the new equipment to be procured under this Project, the target health facilities plan to follow the same procedures as those for their existing equipment. In other words, the hospitals will contract outside local representatives of the equipment manufacturers, and RGD will take care for the maintenance of the equipment of the clinics. At the same time, establishing a system to reinforce daily preventive maintenance, such as cleaning before and after using equipment, is a very effective approach. We would suggest the following methods for the maintenance of the equipment.
1) Maintenance work by each health facility Standard maintenance work required for the equipment procured by the Project should be provided by each health facility in accordance with the procedures described in the operation and maintenance manuals, which come with the equipment.
2) Repair work by the GMTD and by local representatives of manufacturers Ideally, the Project should choose preferentially the types of equipment that could be maintained easily on a daily basis at each target facility. However, more and more medical devices today are electronically controlled and, if broken down, they cannot be repaired easily, as it is difficult to identify the faulty parts within the complicated mechanisms. Examples of such items are patient monitor, infant ventilator, ultrasound diagnostic equipment and X-ray diagnostic equipment. These items need to be serviced by GMTD or the local agents of the equipment manufacturers.
3) Maintenance system of each facility A checkup before and after each use is essential for keeping the performance of any type of equipment at the optimum level. It is ideal that the members of medical staff who use the equipment conduct such daily checkups. Therefore, it is necessary to provide the medical staff with training programs enabling them to perform daily maintenance procedures for equipment.It would be ideal that the supplier of the equipment could provide such daily maintenance training in addition to ordinary operational training at the time of the installation of the equipment. However, in reality, the training sessions provided by the supplier are very basic with limited contents. Thus, in this Project, the consultant will consider additional instructions to include in the Tender Documents to supplement the operational training provided by the supplier, and help health facility staff understand the importance of maintenance and to establish the
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above-mentioned system which enables the health facility staff to perform daily maintenance procedures and repair work.
(6) Policy on Determining the Scope and Grades of Medical Equipment The scope and the grades of the equipment to be procured under this Project shall be determined according to the following guidelines:
・ The equipment should be provided mainly for the clinical departments that are related to the improvement of mother-and-child health. The Project will renew the aged equipment for the target hospitals and provide basic medical equipment necessary to comply with the Primary Healthcare Service Package for the target clinics**.
・ If the installation of certain equipment items requires the Surinamese government to renovate the target facilities and/or conduct the training of personnel to be operating the equipment, such items should be selected only to the extent that such renovation work and/or training is possible.
・ Equipment should be selected within the technical and financial capabilities of the Surinamese side to operate and maintain the equipment.
・ Equipment should be procured only to the extent that they will be able to support the medical activities qualitatively and quantitatively of the target facilities.
**Currently Available Services and Target Levels of Services of the Project As for the two target hospitals, this Project intends to restore their original medical service capabilities by renewing their aged equipment. To the target clinics, the Project will introduce the Primary Healthcare Service Package, according to which they can provide obstetric and neonatal care and simple medical examinations in addition to their current prevention-oriented services. While clinics in general have been incapable of rendering obstetric and neonatal care, our field survey confirmed that two of the five target clinics had began providing delivery services as a result of their own efforts to adopt the Primary Healthcare Service Package.
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Consultation for Need to special pregnant women Appropriate care during who need care of decision-making operation of Hospitalization cardiologist for Emergency case of emer. ope. pregnant with of serious case diabeties anemia of perinatal period (toxiemia of complication in ICU (eclampsia, ･ pregnancy, etc.) diseases bleeding, neonatal X-ray Non ordinal asphyxia ･Ultrasound Hospitalization perinatal ･General lab. Blood Bank consultation of Abdominal of toxiemia of (24 hrs.) Care of threatened toxemia on operation pregnancy, etc. abortion, pregnancy, Emergency case (extrauterine threatened malpresentation of abnormal pregnancy, etc.) premature Rehabilitation delivery at home Hospitalization Consultation Cesarean section of post of after operation Decapitation abnormal for mother safe delivery & Dilatation & surgical care curettage
Ultrasound Normal Observation of Pharmacy ･ General delivery & ･ Normal delivery post natal care ･ Prenatal surgical Lab. exami. as ･ Forceps & treatment routine works Sterilization ･ Family Plan. vacuum delivery (blood, urine, etc.) Nutrition
OPD Emergency OPD Imaging Diagnostic & Delivery Surgical Function Hospitalization Assisted Function (Diagnostic) (Diagnostic) Laboratory (Treatment) (Treatment) (Treatment) (Others) (Diagnostic) Currently Available Services Level of Services at Hospital Level of Services at Clinic Target Services to be achieved by the Project
Figure 2-1 Currently Available Services & Target Level of Services in the Field of Obs. & Gyne.
Care of deformity, congenital anomaly Hospitalization of serious Emergency cases in ICU Care of suspended operations (OPD Care for asphysia or Emergency animation on ･ X-ray & respiratory cases) Blood Bank Consultation of arrival (neonatal) Examination Hospitalzation disorder neonates pathological ･ Ultrasound of respiratory paediatrics ･ General lab. disordered Planned neonates (24 hrs.) operations Rehabilitation Care of Care for bacterial neonatal who infection neonates are referred Hospitalization from clinics of post- operations
Care for low birth weight Care of neonatal babies jaundice Pharmacy ･ Lab. exami. as OPD care Emergency care routine works Small surgical ･ Neonatal for neonatal Sterilization (blood, urine, Neonatal care treatment Hospitalization Consultation etc.) (temp. control) for neonatal care Nutrition
OPD Emergency OPD Imaging Diagnostic After Delivery Surgical Function Hospitalization Assisted Function (Diagnostic) (Diagnostic) & Laboratory Function (Treatment) (Treatment) (Others) (Diagnostic) (Treatment) Currently Availabl Services Level of Services at Hospital Level of Services at Clinic Target Services to be achieved by the Project
Figure 2-2 Currently Available Services & Target Level of Services in the Field of Pediatrics
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(7) Policy for Social Conditions The official language of Suriname is Dutch, which is used in all parts of Surinamese lives from daily conversations to official documents. Although doctors and other highly-educated people understand English, some nurses and laboratory technicians have difficulties reading English documents. Therefore, Dutch translation will be attached to the instruction manuals of the equipment to be operated by nurses and technicians so that they can understand the basic maneuver.
(8) Policy on Work Schedule Surinamese yearly climatic cycle consists of four seasons: minor dry season (March–April), rainy season (May–August), dry season (September–November), and minor rainy season (December–February). The average rainfall during the rainy season from May to August is about 300mm, which could cause flood in many sections of the roads in the country. Thus, it is best to avoid transporting the equipment during this season. Also, since the target health facilities are situated in scattered parts of the country, the inland transportation routes should be carefully worked out when drafting the implementation schedule. If the installation of certain equipment requires the suspension of medical activities at some facilities, the work schedule should be so designed to minimize such interruption.
2-2-2 Basic Plan (1) Overall plan The figure below shows an overview of the Project based on the above design policy. The initial request from the Surinamese Government listed three hospitals (‘sLands, Nickerie, and Albina), Central Laboratory, and three clinics (Wonoredjo, Lelydrop, and Derde Rijweg) as target facilities of the Project. However, Central Laboratory and Albina Hospital were excluded from the Basic Design of the Project as it was confirmed that the former was not engaged in the kind of activities that would have direct impact on the enhancement of mother-and-child care and that the latter was supplied with equipment under the assistance of the French Government after the Surinamese Government sent the request to the Japanese Government. Subsequently, the Surinamese Government submitted another request to add two clinics in the suburb of Paramaribo, namely Tijgerkreek and Koewarasan, to the Project. In response to the additional request, the Japanese Government dispatched a study team to Suriname to verify the necessity and the appropriateness of the inclusion of these clinics. The study team, based on the conclusion that upgrading of these two clinics was necessary for providing enhanced mother-and-child health care services especially for those living in rural areas, decided to add these clinics to the Project.
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1. Basic Structure of the Project (1) Japanese Assistance - Procurement of Medical Equipment - Support for the Establishment of the Operation / Maintenance System of Medical Equipment through the Implementation of Soft Component Program (2) Responsibilities of Suriname - Techn ical Training of relevant Medical Personnel - Renovation of the Clinics
2. Target Health Facilities
Facilities listed on the Original Request Facilities selected after Basic Design Study
1. 'sLands Hospital 1. 'sLands Hospital 2. Nickerie Regional Hospital 2. Nickerie Regional Hospital 3. Albina Hospital 3. Wonoredjo Clinic 4. Central Laboratory 4. Lelydrop Clinic 5. Wonoredjo Clinic 5. Derde Rijweg Clinic 6. Lelydrop Clinic 6. Tijgerkreek Clinic 7. Derde Rijweg Clinic 7. Koewarasan Clinic
Figure 2-3 Contents and Structure of the Assistance Project
Basic guideline for the procurement of medical equipment is to supply or renew the kind of items that are indispensable to the provision of mother-and-child health care services at each target hospital/clinic and necessary for other basic medical care but are lacking or deteriorated. As for the facility renovation, the site survey and subsequent discussions with the Surinamese counterparts confirmed the need for repair work on certain parts of the clinics’ buildings that had leaks or other damages, as well as the X-ray operating rooms of the two hospitals. The Surinamese side will undertake the renovation work. At the two hospitals, general X-rays are currently taken by putting up an X-ray shielding screen while the operator wears a lead apron. To ensure safety, X-ray apparatus should be operated from a shielded operating room. Thus, the existing X-ray rooms will be renovated to create such spaces.
(2) Equipment plan The equipment plan for each clinical department is summarized on determining the policy of scope and grades of medical equipment which were mentioned in above paragraph.
1) Outpatient Department The contents of the equipment include the general and basic equipment for outpatient examination and treatment. Our study found that many of the items had been originally
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acquired by the support of foreign countries some 15 to 20 years ago and had not been replaced or supplemented ever since. As a result, such equipment items are deteriorated, broken down, or quantitatively insufficient. By taking into account the types of medical activities, the medical personnel, and the state of the existing equipment of each health facility, the plan shall be made to replace, add, or procure the equipment as needed.
This Project will procure gynecological examination tables, cardio-tocograph, and ultrasonic diagnostic equipment for the Obs/Gyn Outpatient Department of the ‘sLands Hospital, ECG, defibrillators, and other emergency care equipment for the Emergency Department of Nickerie Regional Hospital, and weighing scales, stethoscopes, sphygmomanometers, ECG, and other basic equipment for the Outpatient Department of each target clinic.
2) Labour and Delivery Room The Delivery Rooms are currently installed with basic equipment. Since most of them have not been replaced or supplemented, they are deteriorated, broken down, and/or became insufficient in number. Replacement, addition, and/or procurement of this equipment shall be planned in consideration of the activities, the personnel, and the present state of the existing equipment of each health facility.
This Project will procure delivery tables, infant warmers, vacuum extractors, doppler fetus detectors, and other basic equipment for the target hospitals and clinics.
3) Nursery The Nurseries require basic equipment to provide care for premature and low-weight babies. Specifically, the Project will provide bilirubin-meters, pulse-oxymeters, phototherapy units, etc. for the target hospitals and clinics.
4) Operation Room This Project will provide equipment for the operation rooms, especially in the field of obstetrics. Our study found that many operating tables were old and could not be vertically adjusted or tilted. As for the anesthetic equipment, the hospitals were using only the basic-type halothane vaporizers. In light of the above, this Project will replace or supplement the deteriorated and/or broken down equipment of the two hospitals.
Specifically, the Project will renew the operating tables, anesthetic equipment,
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electrosurgical-units, and patient monitors of both hospitals and additionally replace the laparoscope and gastrointestinal-fiberscope of Nickerie Regional Hospital.
5) Imaging Diagnostic Department (X-ray and Ultrasound) This Project will procure fluoroscopic X-ray diagnostic equipment, mobile X-ray diagnostic equipment, X-ray film processors and ultrasound diagnostic equipment for the two target hospitals.
6) Central Sterilizing Supply Department (C.S.S.D.) This Project will replace the aged high-pressure steam sterilizers of the two hospitals with the possible addition of water-treatment devices.
7) Laboratory Department This Project will provide equipment for the laboratory departments of the two hospitals and the five clinics. More specifically, the Project will renew the biochemical analyzer, binocular microscopes, centrifuges, and other old and dilapidated equipment of ‘sLands Hospital, and replace the water-distiller, centrifuges, blood cell counter, spectrophotometer, binocular microscopes of Nickerie Regional Hospital. Equipment for the clinics includes binocular microscopes, refrigerators, hot-air sterilizers, spectrophotometers, centrifuges, and water distillers.
Table 2-4 is the final list of the equipment procured for the Project.
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Table 2-4 List of Medical Equipment
(1) ‘sLands Hospital
No. Department Code Name of Equipment Category Q’ty
1 1-1-1 Gynecological Examination Table Replace 2
2 1-1-2 Gynecological Examination Unit Replace 2 Obstetric & Gynecology 3 1-1-3 Cardio Tocograph Replace 1
4 1-1-4 Ultrasound Diagnostic Equipment Replace 1
5 1-2-1 Examination Light Replace 3
6 1-2-2 Delivery Table Replace 6
7 1-2-3 Infant Care Unit Replace 1 Delivery 8 1-2-4 Infant Warmer Replace 3
9 1-2-5 Vacuum Extractor Replace 1
10 1-2-6 Doppler Fetus Detector Replace 3
11 1-3-1 Phototherapy Unit Replace 3
12 Nursery 1-3-2 Bilirubin Meter, Skin Type Newly Introduced 1
13 1-3-3 Pulse Oximeter Replace 2
14 1-4-1 Operating Table Replace 3
15 1-4-2 Anesthesia Apparatus Replace 1 Operation Room 16 1-4-3 Electrosurgical Unit Replace 2
17 1-4-4 Patient Monitor Replace 1
18 1-5-1 Bedside Monitor Replace 2 ICU 19 1-5-2 Defibrillator Replace 1
20 1-6-1 High Pressure Steam Sterilizer Replace 2 Sterilization 21 1-6-2 High Pressure Steam Sterilizer, Table Top Type Replace 1
22 1-7-1 Fluoroscopic X-ray Diagnostic Equipment Newly introduced 1
23 1-7-2 Automatic X-ray Film Processor Replace 1 X-ray / Ultrasound 24 1-7-3 Ultrasound Diagnostic Equipment (Color) Newly introduced 1
25 1-7-4 Mobile X-ray Diagnostic Equipment Replace 1
26 1-8-1 Automatic Chemistry Analyzer Replace 1
27 Laboratory 1-8-2 Binocular Microscope Replace 3
28 1-8-3 Centrifuge, Table Top Type Replace 1
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(2) Nickerie Regional Hospital
No. Department Code Name of Equipment Category Q’ty
1 2-1-1 Resuscitator for Neonatal and Adult Replace 2
2 Emergency 2-1-2 Electrocardiograph Replace 1
3 2-1-3 Defibrillator Newly introduced 1
4 2-2-1 Examination Light Replace 1
5 2-2-2 Colposcope Replace 1 Delivery 6 2-2-3 Suction Unit Replace 1
7 2-2-4 Doppler Fetus Detector Replace 1
8 2-3-1 Infant Warmer Replace 1
9 2-3-2 Infant Incubator Replace 3
10 Nursery 2-3-4 Phototherapy Unit Replace 1
11 2-3-5 Bilirubin Meter, Skin Type Newly introduced 1
12 2-3-6 Pulse Oxymeter Replace 2
13 2-4-1 Anesthetic Apparatus Replace 2
14 2-4-2 Pulse Oxymeter Replace 2
15 2-4-3 Laparoscope Replace 1 Operation Room 16 2-4-4 Gastro-intestinal Fiberscope (Upper and Lower) Replace 1
17 2-4-5 Operating Table Replace 1
18 2-4-6 Patient Monitor Replace 1
19 Sterilization 2-5-1 High Pressure Steam Sterilizer Replace 1
20 2-6-1 Fluoroscopic X-ray Diagnostic Equipment Newly introduced 1
21 2-6-2 Automatic X-ray Film Processor Newly introduced 1 X-ray / Ultrasound 22 2-6-3 Ultrasound Diagnostic Equipment Replace 1
23 2-6-4 Mobile X-ray Diagnostic Equipment Replace 1
24 2-7-1 Water Distilling Equipment Replace 1
25 2-7-2 Centrifuge, Table Top Type Replace 1
26 2-7-3 Hematocrit Centrifuge Replace 1
27 Laboratory 2-7-4 Automatic Blood Cell Counter Replace 1
28 2-7-5 Differential Leucocyte Counter Replace 1
29 2-7-6 Spectrophotometer Replace 1
30 2-7-8 Binocular Microscope Replace 1
31 Pharmacy 2-8-1 Water Distilling Equipment Replace 1
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(3) 5 Clinics
No. Department Code Name of Equipment A B C D E Q’ty
1 3-1-1 Weighing Scale, Adult 1 ○ 1 ○ 1 ○ 1 ○ 1 ○ 5
2 3-1-2 Stethoscope, Dual Type 1 ● 1 ● 1 ● 1 ● 1 ● 5
3 3-1-3 Sphygmomanometer 1 ○ 1 ○ 1 ○ 1 ○ 1 ○ 5
4 3-1-4 Diagnostic Set 1 ● 1 ● 1 ● 1 ● 1 ● 5 Outpatient 5 3-1-5 Small Operating Instrument Set 2 ○ 2 ● 2 ● 2 ● 2 ● 10
6 3-1-6 Electrocardiograph 1 ● 1 ● 1 ● 1 ● 1 ● 5
7 3-1-7 Examination Light 1 ● 1 ● 1 ○ 1 ○ 1 ○ 5
8 3-1-8 Sterilizer, Table Top Type 1 ● 1 ● 1 ○ 1 ○ 1 ● 5
9 3-2-1 Weighing Scale, Infant 1 ○ 1 ○ 1 ○ 1 ○ 1 ○ 5
10 3-2-2 Resuscitator 1 ○ 1 ○ 1 ● 1 ● 1 ● 5
11 3-2-3 Delivery Table 1 ○ 1 ● 1 ● 1 ○ 1 ○ 5 Delivery 12 3-2-4 Suction Unit 1 ○ 1 ● 1 ● 1 ● 1 ● 5
13 3-2-5 Doppler Fetus Detector 1 ● 1 ● 1 ● 1 ● 1 ● 5
14 3-2-6 Examination Light 1 ● 1 ● 1 ○ 1 ○ 1 ○ 5
15 3-3-1 Infant Incubator 1 ● 1 ● 1 ● 1 ● 1 ● 5
16 3-3-2 Infant Warmer 1 ● 1 ● 1 ● 1 ● 1 ● 5 Nursery 17 3-3-3 Phototherapy Unit 1 ● 1 ● 1 ● 1 ● 1 ● 5
18 3-3-4 Bilirubin Meter, Skin Type 1 ● 1 ● 1 ● 1 ● 1 ● 5
19 Ultrasound 3-4-1 Ultrasound Diagnostic Equipment 1 ● 1 ● 1 ● 1 ● 1 ● 5
20 3-5-1 Binocular Microscope 1 ○ 1 ○ 1 ○ 1 ○ 1 ● 5
21 3-5-2 Refrigerator 1 ○ 1 ○ 1 ○ 1 ○ 1 ○ 5
22 3-5-3 Drying Oven 1 ○ 1 ● 1 ○ 1 ○ 1 ○ 5
23 3-5-4 Test Tube Mixer 1 ● 1 ● 1 ● 1 ● 1 ● 5
24 3-5-5 Differential Leucocyte Counter 1 ● 1 ● 1 ● 1 ● 1 ● 5 Laboratory 25 3-5-6 Bilirubin Analyzer 1 ● 1 ● 1 ● 1 ● 1 ● 5
26 3-5-7 Spectrophotometer 1 ● 1 ● 1 ● 1 ● 1 ● 5
27 3-5-8 Centrifuge, Table Top 1 ○ 1 ○ 1 ○ 1 ● 1 ● 5
28 3-5-9 Hematocrit Centrifuge 1 ● 1 ● 1 ● 1 ● 1 ● 5
29 3-5-10 Water Distilling Equipment 1 ● 1 ● 1 ● 1 ● 1 ● 5 Notes: A: WonoredjoClinic, B: Lelydorp Clinic, C: Derde Rijweg Clinic, D: Tijgerkreek Clinic, E: Koewarasan Clinic ○:Replacement, ●: Newly introduced
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2-2-3 Basic Design Drawing (Installation Plan of the Major Equipment) The installation plan of the Fluoroscopic X-ray Diagnostic Equipment and High Pressure Steam Sterilizer of the 2 hospitals are referred as the following figures:
(Bucky Stand) Control Room
(X-ray Controller)
(Fluoroscopic Table)
Fluoroscopic X-ray Room
Installation Plan of tne Fluoroscopic X-ray Diagnostic Equipment (‘sLands Hospital)
Equipment which will be installed (2 units)
Preparation Room
Slope
Installation Plan of the High Pressure Steam Sterilizer (‘sLands Hospital)
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Control Room
(X-ray Controller)
Fluoroscopic X-ray Room
(Bucky Stand)
(Fluoroscopic Table)
Installation Plan of the Fluoroscopic X-ray Diagnostic Equipment (Nickerie Regional Hospital)
Store (New Equipment)
Supply Department Existing Equipment
Shower Room
Preparation Room
Reception
Installation Plan of the High Pressure Steam Sterilizer (Nickerie Regional Hospital)
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2-2-4 Implementation Plan 2-2-4-1 Implementation Policy (1) Standard implementation procedure Based on this report, related governmental agencies of Japan reviews the contents of this proposed Project, and, following the approval of the Japanese Cabinet, the Exchange of Notes (E/N) will be officially executed by and between the governments of Japan and Suriname under the framework of the Grant Aid system of the Japanese government. In accordance with the E/N, the consultant and the equipment supplier for this Project will conclude agreements with the government of Suriname, which are to be approved by the Japanese government.
(2) Implementation schedule This Project consists of the procurement and installation of medical equipment, which needs to be done without interrupting the medical activities of the target facilities. Thus, the entire work process is estimated to take about twelve months.
(3) Procurement procedure The equipment supplier shall be selected through a competitive tender open to the Japanese companies in accordance with the grant aid scheme.
(4) Project implementation system The Project shall be implemented under the supervision of the MOH. The MOH shall be the party on the Surinamese side to the Design/Supervision Contract, Equipment Procurement Contract, Banking Arrangement (B/A), and other such agreements to be concluded for this Project. The Project Planning and Execution Department of the MOH and the Regional Health Service (RGD), which has jurisdiction over the two hospitals and the five clinics, are in charge of coordinating discussions on the technical matters and other businesses related to the Project.
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Ministry of Health Project Implementing Organization Project Planning and Execution Department (Contractor)
Coordination in Technical Fields
Ministry of Health ・Maintenance Department ・Regional Health Services (RGD) (Agreement / Contract) ・'sLands Hospital ・Nickerie Regional Hospital ・5 Clinics
(Japanese Corporations)
Consultant (Project supervision) Equipment Supplier (procurement and installation of equipment)
Figure 2-4 Project Implementing System
(5) Roles of the consultant and equipment supplier 1) Consultant After the signing of the E/N, the MOH shall conclude the consultancy agreement on tender-related works and the supervision of the Project with the Japanese consultant company, and the Japanese government shall verify said agreement. For the smooth implementation of the Project, it is important to conclude the agreement immediately after signing of the E/N. After the Japanese government verifies the agreement, the consultant shall start services such as preparation of tender documents, obtain the approval, conduct the tender, and supervision of the implementation of the Project.
2) Equipment Supplier The contractor to procure and install the equipment for the Project shall be selected through tender. As a rule for the tender, the bidder offering the lowest price shall be the successful bidder. The contractor will then conclude the supply contract with the successful bidder of the equipment and obtain the verification of the Japanese government. The contractor shall complete required works in the contract and handover the equipment to the MOH after the final inspection.
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2-2-4-2 Implementation Conditions In implementing the Project, special attention shall be paid to the following points.
(1) To minimize the interruption of medical services during the installation period Because health facilities covered by the Project continue the daily medical care services during the installation work, the period in which the services are interrupted must be minimized. In order to minimize the interruption, the procurement process of the equipment shall be strictly supervised, and the installation and inspection schedule shall be formulated through discussion in advance and strictly observed with those related to the health facilities. Especially at the time of installation, safety measures shall be taken for the patients and the medical staff.
(2) Inland transportation routes in Suriname Large cargo vessels can enter Paramaribo Port. Although the target health facilities are located in scattered areas in northern Suriname, the equipment will be unloaded at Paramaribo Port and therefrom transported to the respective sites by container truck. However, for ‘sLands Hospital and some clinics in the Paramaribo Metropolitan Area, where larges truck are difficult to enter, pickup tracks may be used.
(3) Customs clearance and tax exemption procedure In implementing the Project, services conducted by the Japanese nationals such as the consultant and the equipment supplier, as well as the procured equipment, shall be exempted from all taxes imposed by the domestic law of Suriname. However, since difficulties may be anticipated during the course of customs clearance and tax exemption procedure, it is necessary for the consultant to pay sufficient attention to those issues by alerting the related agencies and confirming the necessary procedures.
2-2-4-3 Scope of Works The Project shall be implemented under the cooperation of the governments of Suriname and Japan. The works to be borne by both parties are as follows.
(1) Works to be carried out by the government of Japan Japanese side shall: 1) execute the procurement of the equipment on the Project, 2) transport the equipment to the respective health facilities, which includes marine and inland transportation in Suriname,
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3) install and set up the equipment, and 4) perform the test run, give instructions for operation and maintenance and do final inspections for all the equipment.
(2) Works to be carried out by the Government of Suriname Surinamese side shall: 1) present data, documents, and other information necessary for the installation and set up of the equipment 2) remove old equipment and prepare the rooms to which the new equipment is to be installed, 3) prepare facility infrastructure, such as electricity, water supply, and sewage lines, in the sites where the new equipment will be installed, 4) provide places to unload the equipment, 5) temporary storage spaces for the equipment until the installation, 6) secure delivery routes for the equipment, 7) conduct training of medical staff, and 8) complete the renovation work for the clinics.
2-2-4-4 Consultant Supervision Based on the Japanese grand aid scheme, the Japanese consultant shall conclude the consultancy agreement with the MOH. In compliance with this agreement, the consultant shall provide services of planning and holding a tender and of overseeing the implementation of the Project. The consultant shall check documents prepared by tenderers in such points as whether the procurement is executed as scheduled, or whether the procured equipment is meeting the specifications stipulated in the tender documents, etc. The purpose of the work is to ensure proper execution by the equipment supplier. The consultant offers advice and guidance for any adjustments in the implementation of the Project. This supervisory work includes the followings.
(1) Assisting with tender procedures and contracting To select a Japanese trading company to take charge of the equipment procurement/installation work, the consultant will prepare tender documents, announce a tender publicly, accept applications from applicants, distribute tender documents to tenderers, accept tenders offered, evaluate the results, and give advice to the recipient to conclude a contract with the successful tenderer.
(2) Instructions, advice and coordination for the supplier The consultant shall examine the work schedule and provide instructions and advice to the supplier.
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(3) Inspection and approval of the manufacturing documents and installation layout The consultant shall examine and approve manufacturing documents and installation layout, and other necessary documents submitted by the supplier.
(4) Report of the progress of the Work The consultant monitors the condition of the sites and the implementation of the Project and reports the progress of the works to the authorities of both governments.
(5) Inspection and testing upon completion The consultant shall attend the on site inspection and trial operation of the equipment in order to confirm that the equipment is consistent with the provisions of the contract. Final inspection reports shall be submitted to authorities concerned on the Surinamese side.
(6) Training in maintenance and operation of the equipment Equipment to be procured in the Project requires basic maintenance and operation skills. It will be necessary to train the medical and maintenance staff in operation and troubleshooting of the equipment during the period of installation, adjustment, and test running. The consultant shall give necessary instructions for the training programs.
2-2-4-5 Procurement Plan The following points shall be noted in procuring equipment in the Project.
(1) Guidelines for origin of the equipment Since no medical equipment is produced in Suriname, it will be procured from other countries. As explained in the basic design policy, such main equipment items as X-ray apparatus and ultrasound diagnostic equipment will be procured from Japan or third countries. Based on the degree of difficulty in maintaining the equipment and the necessity of after-sales services, the equipment items to be procured and their origins, as well as incidental conditions that need to be taken into account, were set forth as follows:
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Name of Equipment Country of Origin Place of Agent(s) X-ray Diagnostic Equipment, Ultrasound Diagnostic Equipment, X-ray Film DAC countries Suriname Processor Electro-surgical Unit, Endoscope, Blood Cell Counter, Chemistry Analyzer, DAC countries Suriname, or Anesthesia Apparatus, Patient Monitor, Cardio Tocograph, Electrocardiograph, Netherlands, Venezuela Pulse Oximeter, Operating Table, Delivery Table, Gynecology Examination Table, Treatment Unit, Infant Incubator, Infant Care Unit, Infant Warmer, Colposcope, Phototherapy Unit, Binocular Microscope, Spectrophotometer, Autoclave Bilirubin Meter (Skin), Suction Unit, Doppler Fetus Detector, Water Distilling DAC countries Surinmae, or Equipment, Bilirubin Meter, Drying Overn, Autoclave, Centrifuge, Mixer Netherlands, Venezuela, USA Operating Instruments Set, Examination Light, Sphygmomanometer, DAC countries Stethoscope, Resuscitator, Weighing Scale, Diagnostic Set, Leucocyte Counter, Refrigerator
(2) Transportation period The equipment to be procured from Japan and the third countries need approximately four weeks for the marine transportation, additional two to four weeks for the customs clearance, and about ten days for the inland transportation, altogether thirty-five to forty days.
2-2-4-6 Implementation Schedule After the signing of the E/N by both governments, the Project will be implemented in the following two stages; tender and tender-related works and procurement and installation of the equipment.
(1) Tender and tender-related works After signing of the consultancy agreement between the MOH and the consultant, and after verification of the said agreement by the government of Japan, the preparation of tender and tender-related works will start. The tender and tender-related works include final confirmation of the technical specifications of the equipment and preparation of the instructions to tenderer(s). This set of documents needs to be approved by the Surinamese side. Then, the consultant shall announce the tender publicly, and call for applications for tendering, distribute the tender documents to applicants, hold the tender, evaluate the submitted documents from applicants, nominate the winner and help to conclude the supply contract between the MOH and the supplier. This stage takes about four months.
(2) Procurement and installation of the equipment After the Japanese government verifies the supply contract between the MOH of Suriname and the equipment supplier, the supplier starts procuring the equipment in compliance with the contract documents. The works related to the equipment procurement, transportation and installation in the
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health facilities takes about eight months.
The implementation of the Project is scheduled from the signing of the E/N to the completion of the works as shown in Figure 2-5.
Month １２３４５６７８９10 11 12 Item
（Total 4 months） Detail Design
Preparation of Tender Documents Tender Preparation and Tendering Stage Confirmation of Tender Documents
Tender Notice
Tendering, Tender Evaluation & Supply Contract
（Total 8 months） Manufacturing & Procuring
Procurement Transportation and Installation Stage Installation & Regulation
Training
Soft Component
Work in Suriname Work in Japan
Figure 2-5 Implementation Schedule
2-3 Obligations of the Government of Suriname
2-3-1 Training Sessions and Renovation Work of the Clinics The table below outlines the contents of the technical training sessions of the medical staff to be executed by the Surinamese side in connection with the implementation of this Project. Basically, these training sessions are to transfer certain medical techniques, which are being used in the daily practices at Paramaribo University Hospital and s’Lands Hospital, to the healthcare workers of target health facilities, who already possess basic knowledge of delivery, neonatal care, and laboratory tests. Therefore, the feasibility of such training sessions is deemed high. Before Project implementation, the Surinamese side was established the committee for planning and implementation of the training program. The committee members and the contents of training sessions are indicated below tables.
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Member of the Training Committee
Name Organization Speciality Mr. Manoji Hindori MOH Project Coordinator Dr. Carlos Van Lierop Paramaribo University Hospital Specialist for Obs. & Gyne. Dr. Prem Goerdin Paramaribo University Hospital Specialist for Obs. & Gyne. Dr. O. Ristie ‘sLands Hospital Specialist for Obs. & Gyne. Dr. S.R. Mohan ‘sLands Hospital Specialist for Obs. & Gyne. Dr. Aikman Helen MOH, RGD Specialist for Obs. & Gyne.
Table 2-5 Contents of Training Sessions to be Organized by the Surinamese Side
Category of Training Stage 1: Academic Training Stage 2: Practical Training (1)-A - General guidance for obstetrics care; - Confirm the gestational sac, GS; Obstetrical ultrasonographic - Diagnosis of normal pregnancy or not (multiple - Confirm the yolk sac; diagnosis in the first trimester pregnancy, ectopic pregnancy, etc.); - Measuring the crown-rump length, CRL; (early stage in pregnancy) - Confirm the amniotic membrance; - Heart rate (5 weeks; 90-100bpm, 9 weeks; 170-180bpm, 16 weeks; 150bpm); - Diagnosis the ectopic pregnancy; - Diagnosis the fetal abnormalities (1)-B - General guidance for obstetrics care; - Screening the fetal well-being; Obstetrical ultrasonographic Abdominal scanning, Fetal well-being, fetal - Diagnosis the fetal abnormalities; diagnosis during mid-and late abnormalities, Volume of aminiotic fluid, Umbilical - Confirm the aminiotic fluid; pregnancy cord, Diagnosis of placenta, etc. - Confirm the umbilical cord (blood flow) (2) Ultrasonography in - General guidance for gynecological care; - Diagnosis of utrus, ovarium, urinary bladder, gynecology Hysteromyoma, Pyo-ovarium, etc. rectal, etc. (3) Ultrasonography in obstetrics - General guidance for diagnosis by ultrasound - Blood flow of unbilical cord and gynecology color Doppler (4) Laparoscopy - General guidance for diagnosis and treatment by - Suction of ovarian cyst; laparoscope - Endometriosis; - Adhesiotomy / Synechiotomy - Hysteromyoma (5) Electrocardiogram - General guidance for electrocardiogram - Diagnosis waveform of ECG (6) Laboratory skills - General guidance for biochemistry - Measuring and reading of testing parameters Source) Planning Department, Ministry of Health, Suriname
Table 2-6 summarizes the necessary renovation works for the clinics, which was presented to the Surinamese government officials by the Study Team. Works indicated by “A” are essential for the implementation of the Project and, if executed, will provide necessary infrastructure for the equipment to be installed under the Project.
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Table 2-6 Contents of the Renovation Works to be Presented by the B/D Study Team (in US$)
Category Wonoredjo Lelydrop Derde Rijweg Tijgerkreek Koewarasan Floor Area 336.0m2 428.8m2 132.3m2 366.0m2 132.3m2 Construction 1981 1972 1970 1970 1968 Contents of Renovation Works Contents Installation of distribution board and additional 3 electricity circuits Electricity Priority A A A A A Costs 341.40 341.40 341.40 341.40 341.40 Contents Renovation Renovation Renovation Roof Priority A A A Costs 6,429.00 5,446.68 6,285.54 Contents Print tiling Print tiling Print tiling Floor Priority B B B Costs 14,757.60 21,840.00 11,421.54 Door & Contents Renovation Renovation Renovation Windows Priority A A A Costs 3,529.50 1,000.00 1,239.30 Site Drainage Contents Site drainage Site drainage Site drainage Priority A A A Costs 1,188.00 2,567.70 1,663.20 Subtotal (only priority A) 7,958.40 3,870.90 9,955.78 8,290.14 1,580.70 Total (Priority A) 31,655.92 Notes: Priority A: Necessary renovation works for the Project execution. Priority B: Renovation works to be done by the Surinamese side if possible. * Costs of renovation works examined and presented by the KDV Architects, Paramaribo, Suriname. * Cost estimation of electricity renovation works (installation of additional 3 electricity circuits, single-phase 220V） (1) Cost of Materials ･PVC Cable (single-phase 220V 3x4mm2): US$1.39 x 40m = US$55.60 Total: US$55.60 x 3 sets = US$166.80 ･Socket (Single Phase 220V): US$11.00, Total: US$11.0 x 3 = US$33.00 ･Cable Clamps (12mm): Total: US$1.20/25 pcs./set x 6 sets = US$7.20 ･Distribution Board (220V, for 2 groups) Total: US$52.2 0 x 2 pcs. = US$104.40 (2) Cost of Installation Total: US$25.00 man/day x 3 days = US$150.00 Total (1) + (2): Cost of Materials (US$311.40) + Cost of Installation (US$30.00/1 clinic) Source) Survey on Basic Design Study
2-3-2 Other Obligations for the Project Other obligations of the government of Suriname in relation to the implementation of the Project are as follows:
(1) to provide the necessary information and data for the Project, (2) to provide support for the supplier, such as prompt customs clearance of the equipment under the Project at ports of disembarkation in Suriname, (3) to exempt Japanese nationals who are staying in Suriname for providing services in connection to the implementation of the Project, from customs duties, internal taxes and fiscal levies which may be imposed in Suriname, (4) to accord necessary security and protection to Japanese nationals entering or staying in
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Suriname for the purpose of providing services and to their equipment brought in for the implementation of the Project, (5) to conduct the Banking Arrangement (B/A), and to pay commissions associated with the issuance of the Authorization to Pay (A/P). (6) to allocate the personnel/budgets required for the effective implementation of this Project (including operation and management costs of equipment procured using grant aid), (7) to ensure that the equipment procured under this Japanese Grant Aid Project is maintained and used properly and effectively, (8) to provide necessary permission, licenses, and other authorization for implementing the Project, if necessary, (9) to pay fees and charges associated with tax exemption procedures for the Project, (10) collection and control of data and information of the usage of the equipment to be procured under this Project, and (11) to bear all other expenses associated with the implementation of the Project.
2-4 Project Operation Plan
The Planning Bureau, the direct subordinate organ to the Vice Minister of the MOH, is responsible for the supervision and the implementation of the Project and assistance programs. Staffed by a director and an officer, the Planning Bureau serves as a liaison office for negotiating with international organizations and foreign countries and in charge of facilitating and supervising assistance programs by donor organizations and countries.
The operation and maintenance of the Project is to be carried out efficiently by each target hospital/clinic under the supervision of the MOH. However, daily operation and maintenance after the completion of the Project will be done by the two hospitals and RGD (five clinics) as present.
As described in the section 2-6, Soft Component Program, the target hospitals and clinics do not have an established chain of command to process information related to equipment operation and maintenance, such as the procurement of expendable supplies and repair work. Establishment of an operation/maintenance system is urgently needed to coordinate efforts with external organizations and to systematically control various documents, especially operation manuals, related to the equipment to be procured by the Project.
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Minister Director of Health
･Personnel Affairs ･Public Relations, Ministry of Health ･Financial Affairs ･Legal Affairs, Ministry of Health ･General Affairs ･ Planning, Ministry of Health ･Expedition Medical Committee ･Maintenance External Relations
Inspectorate: ･Medical occupations ･Occupations in nursing & care ･Pharmaceuticals & pharmaceutical occupations Bureau of Public Health, Director ･Epidemiology/Biostatistics, Head of Department ･Health Education, Head of Unit ･Administrative Affairs, Sub-director ･Social Healthcare, Sub-director (FP, Medical Pedagogic Bureau, TB Program, EPI, MCH, Nutrition, School Health)
･Environmental Hygiene, Sub-director (Environmental Inspection, Vector Control, Malaria Control Central Laboratory, Food Inspection) ･National AIDS Program, Coordinator ･Dermatological Services ･Foundations & Institutes
･Psychiatric Center
･Paramaribo University Hospital ･ 'sLands Hospital
･ Diakonessen Hospital (Private) ･ Nickerie Regional Hospital ･ St. Vincent Hospital (Private) ･State Health Insurance Fund (SZF) ･ Regional Health Services (RGD) ･Medical Mission (Private)
Figure 2-6 Organizational Structure of MOH and Affiliated Institutions
2-5 Cost Estimation of the Project
2-5-1 Cost Estimation of the Project The cost estimation of the Project is calculated as following two tables. The estimated cost of the Japanese assistance (Table 2-7) is provisional and would be further examined by the Government of Japan for the approval of the Grant.
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($Table 2-7 Estimated Cost of the Japanese Assistance (in ٛ thousand US Item Estimated Costs ‘sLands Hospital Obstetric & Gynecology 25.0 US$1,043.2 Delivery and Nursery 91.8 (¥125M) Operation Room, ICU, Sterilization 333.9 X-ray / Ultrasound 525.8 Laboratory 66.7 Nickerie Regional Hospital Emergency 33.4 US$843.0 Medical Delivery and Nursery 50.1 (¥101M) Equipment Operation Room, Sterilization 292.1 X-ray / Ultrasound 417.3 Laboratory, Pharmacy 50.1 5 Clinics Outpatient 83.4 US$517.3 Delivery and Nursery 166.9 (¥62M) Ultrasound 150.2 Laboratory 116.8 Consultants’ Supervision US$333.8 (¥40M) Currency rate: US$1.00=119.80 Japanese yen.
Table 2-8 Estimated Costs to be covered by the Surinamese side for the Project (in US$) Item Estimated Costs Cost of renovation works for 5 Clinics US$32,000.00 (¥3.8M)* Notes: *: Figures were delivered from Table 2-6. Currency rate: US$1.00=119.80 Japanese yen.
Condition of the Estimation Date of estimation : June 2003 Currency exchange rate : 1US dollar = 119.80 Japanese yen Duration of working design and supervision :Approx. 12 months Purchase order : Lump Sum Other : This Japanese Assistance will be implemented according to the Japanese grant aid system.
2-5-2 Operation and Maintenance Costs (1) Operational Status of the Target Facilities Table 2-9 shows the breakdown of expenditures of the two target hospitals. Although both are public institutions, they generate income mostly by collecting medical fees from the patients under the accounting systems designed and administered by the management of the respective hospitals at their discretion. In both hospitals, personnel expenses, which only cover the wages of the staff directly employed by the hospitals, account for more than half of their respective total expenditures. Salaries and wages of MOH personnel are covered by the MOH. At Nickerie Regional Hospital
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for instance, 74 of the total of 220 staff members are direct employees of MOH, whose remunerations are not included in the hospitals’ accounts. Expenses for medical supplies, expendable goods necessary for the operation of medical equipment, and contractors’ fees for maintenance services are all covered by medical charges. Since this Project will be replacing old equipment, it will not likely incur additional expenses, or if any, they will be covered by the increased revenues generated by the new equipment. Therefore, the current financial systems will be sufficient to cover the operation and maintenance costs of the new equipment to be procured under this Project, as long as the supply sources of spare parts and other expendables are carefully chosen.
Table 2-9 Actual Expenditures of the Hospitals in FY 2002 (in Sf.)
Items ‘sLands Hospital Nickerie Regional Hospital Personnel emoluments 8,105,395,846.58 2,864,279,234.68 X-ray 1,152,677.86 1,850,000.00 Laboratory 272,324,367.53 113,979,745.13 Pharmaceutical 3,330,131,650.69 964,046,556.55 Medical Disposal 305,441,899.69 82,771,647.00 Maintenance (by outside contractors) 19,023,118.33 22,687,500.00 Others 3,360,710,470.40 747,296,114.64 Total 15,394,180,031.00 4,796,910,798.00 Currency rate: 1Japanese yen =22.90 Sf. Source) ‘sLands Hospital and Nickerie Regional hospital
The northern coastal area under the jurisdiction of RGD consists of eight districts, but is divided into nine medical regions according to the population density and accessibility to health facilities. For instance, the densely populated Wanica district is divided into four medical regions, whereas the sparsely populated Coronie and Nickerie districts jointly form one medical region. Clinics are classified into Health Center, Basic Clinic, and Help Post according to the allocation of healthcare workers. The target clinics are comprised of three Health Centers and two Basic Clinics.
Each clinic is managed by RGD and staffed by MOH personnel who are public servants. Table 2-10 shows the breakdown of operational expenses of each target clinic. The operation/maintenance expenses of the equipment to be newly procured by the Project must be covered by medical fees generated by using such equipment. Although the clinics’ existing equipment is maintained by RGD engineers, the new equipment should preferably be serviced by GMTD or other outside local representatives of the equipment manufacturers under maintenance service contracts.
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Table 2-10 Actual Expenditures of the 5 Clinics in FY 2002 (in Sf.)
Items Wonoredjo Lelydrop Derde Rijweg Tijgerkreek Koewarasan Personnel emoluments 218,959,000.56 258,335,929.84 158,139,605.91 140,757,809.03 127,804,852.30 Electricity 1,481,070.00 1,089,300.00 1,268,335.00 711,120.00 1,520,885.00 Telephone 3,161,299.68 2,748,853.80 1,485,370.41 1,353,172.99 3,553,594.27 Water - 2,635,100.00 206,500.00 - - Stationary 222,299.70 273,600.00 332,650,00 104,510.00 257,850.00 Maintenance of facilities 702,330.00 234,815.02 438,725.00 480,065.00 190,650.00 Others* 11,455,531.10 11,235,407.90 1,706,933.00 5,787,164.11 1,467,655.00 Total 235,981,531.04 276,553,006.56 163,578,119.82 149,193,841.13 134,795,486.57 Note: Includes the costs of medical disposal and equipment maintenance. Source) RGD, Ministry of Health, Suriname
(2) Financial Feasibility on the Surinamese Side As mentioned in the Minutes of Discussion (M/D) signed on March 2003, the MOH will secure the appropriate funds for the renovation works of the clinics that are necessary for the implementation of the Project.
The operational expenses of the newly procured equipment will be borne by the respective hospitals or by RGD for the clinics. The operational expenses of the existing equipment, which consist of the expenses for purchasing spare parts and expendables and the payment for maintenance services provided by outside local representatives, are sufficiently being covered by medical fees collected from patients. Thus, the operation of the new equipment is deemed feasible, as the use of the equipment will generate additional income.
However, since some of the equipment items to be procured by this Project will be additional or supplemental to the existing equipment, whether or not they will be able to cover their own expenses needs to be examined. Table 2-11 shows the estimated annual operational costs of main equipment items, and Table 2-12 shows the ratio of the additional running cost in relation to the total running cost in FY2002. In Table 2-13, additional patients and revenues to be generated by introducing the ECG and ultrasound diagnostic equipment to the clinics are estimated. The amount of revenues from medical charges depends on the number of patients. Considering the facts that Surinamese government has launched a campaign to encourage prenatal examinations and that incidence of so-called “Common Diseases”, such as diabetes and hypertensions is on the rise, and based on the recent operation/accounting records of the target clinics, the estimated numbers of ECG and ultrasound diagnosis patients submitted by the Surinamese government seem to be within reasonable ranges.
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Based on the above facts, the ratios of the increase in operational costs in relation to the FY2002 figures are estimated at 6.68% for ‘sLands Hospital and 13.91% for Nickerie Regional Hospital. It was also confirmed that the clinics would be able to cover the running cost by appropriating the revenues from medical fees generated by using the new equipment. In view of the above, the Surinamese side is deemed financially capable of operating the equipment.
Table 2-11 Estimated Annual Running Cost of Main Equipment (in Sf.)
Name of Facility ･ Equipment Q’ty Consumables Spare Parts Total (1) ‘sLands Hospital Fluoroscpic X-ray Diagnostic Equipment 1 Sf.9,090,600 Sf.10,996,800 Sf.20,087,400 (2) Nickerie Regional Hospital Fluoroscpic X-ray Diagnostic Equipment 1 Sf.9,090,600 Sf.10,996,800 Sf.20,087,400 (3) 5 Clinics Electrocardiograph 5 Sf.439,872 - Sf.439,872 Ultrasound Diagnostic Equipment 5 Sf.2,749,200 Sf.29,324,800 Sf.32,074,000 Sub Total Sf.32,513,872
Table 2-12 Examination of Financial Feasibility at each Health Facility (in Sf.)
Name of Health Facility 2002 Record* (A) Estimated Costs (B) (B) / (A) (1) ‘sLands Hospital Running Costs Sf.300,527,469 Sf.20,087,400 6.68% (2) Nickerie Regional Hospital Running Costs Sf.144,344,019 Sf.20,087,400 13.91% (3) 5 Clinics Running Cost Sf.1,289,833 Estimated revenues from medical fees** Sf.39,600,000 - Sub Total Sf.40,889,833 Sf.32,513,872 79.51% Notes: *: Figures of 2002 were derived from Tables 2-9 and 2-10. **: Figures of estimated costs was from Table 2-13.
Table 2-13 Estimated Revenues from Medical Fees (in Sf.)
Medical Services Wonoredjo Lelydrop Derde Rijweg Tijgerkreek Koewarasan Ultrasound 6,000,000.00 6,000,000.00 10,500,000.00 4,500,000.00 3,000,000.00 Electrocardiograph 1,920,000.00 1,920,000.00 1,920,000.00 1,920,000.00 1,920,000.00 Total Revenues 7,920,000.00 7,920,000.00 12,420,000.00 6,420,000.00 4,920,000.00 Total 5 Clinics: 39,600,000.00 (≠J.Y. 1,729,000.-) Estimated number of patients per year Ultrasound 400 400 700 300 200 Electrocardiograph 240 240 240 240 240 Note: Ultrasound charge: Sf.15,000.00/test, Electrocardiograph charge: Sf.8,000.00/test
Estimation of the Number of Patients Using the Ultrasound and ECG at RGD: The number of patients to be using the ultrasound diagnostic equipment is estimated based on the number of prenatal examinations in 2002. At Wonoredjo Clinic, for instance, the total number of patients was 262, of which the vast majority were first-time visitors and only a few re-visit or third checkup (other clinics have similar records). The estimated numbers are based on two prenatal examinations per person, the target value set by RGD (the figures actually used were about 1.5 times the records of 2002).
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RGD estimated the number of ECG examinations based on the assumption that about 10% of outpatients would be needing ECG. Clinic doctors stated that about 10% of 30 to 40 outpatients visiting the clinic daily had heart conditions resulting from unhealthy lifestyles, and ECG was necessary for observing the conditions of such patients, as well as for preventive purposes. Such statements confirm that RGD’s projection is reasonable or perhaps underestimating. The number of patients at Wonoredjo Clinic, for instance, is estimated at 240 per year. This translates into less than one patient per day assuming that the clinic is open 20 days per month. As apparent in records of 2002, the assuming number of outpatients would far exceed the RGD’s statements. Source) Regional Health Services, Ministry of Health, Suriname
2-6 Soft Component Program
(1) Objectives The target sites of the Projects do not have an established chain of command for processing information concerning the operation and maintenance of equipment. At the two target hospitals, some clinical departments directly contact outside vendors to provide expendable supplies and repair services, while others report to the administrative division to take necessary actions. Lack of organization-wide rules and procedures should be rectified urgently by establishing a central system to control the documentation related to the equipment to be procured by this Project, including control ledgers and various manuals, as well as the coordination with external organizations. Under these circumstances, the Soft Component Program will be implemented in the two hospitals and RGD to help them establish the operation/maintenance system of the medical equipment by efficiently deploying limited human resources so that the equipment will be smoothly put into operation after handover.
(2) Outcomes The equipment to be procured under this Project will be operated in a sustainable manner.
(3) Activities Activity 1: Organizing the Project Operation Unit (POU).
･Activity Plan 1-1: POU organizing sessions will be held with the persons in charge of the RGD and the two hospitals. Activities Output Leader Participants 1-1-1 Organization Structures ･RGD ･RGD Consultations for the organization of the ･Directors of 2 hospitals ･Directors of 2 hospitals POU ･Representatives of the departments concerned ･Consultant
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[Example] (Project Leader)
Coordinator
Maintenance & Management Budget / Accounting Supply Security
Facilities Machinery / Utility Equipment Coordinator for Clinical Departments
Activity 2: Establishment of the Equipment Management System (*EMS: following flow)
Survey of the present conditions of the existing equipment (Distinction between these items and those to be procured under the Project) ↓ Procurement of Equipment (Preparation of inventory) ↓ Usage ↓ Establishment of an equipment maintenance system and execution of maintenance work ↓ Replacement of superannuated or deteriorated equipment with new ones
･Activity Plan 2-1: Survey of present situations of the existing equipment (Summarizing of previous inventory data) Activities Output Leader Participants 2-1-1 List of inventories of existing ･RGD (Maintenance) ･RGD, maintenance Summarizing of previous equipment data as equipment ･Hospitals (Maintenance) ･Hospitals, maintenance prescribed by hospitals and / or the MOH ･Consultant
･Activity Plan 2-2: After bidding, short courses on the items 2-2-, 2-2-3 and 2-2-4 below are to be given. These short courses are to be participated in by prime contractor and representatives of mainstay manufacturers of the medical equipment.
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Activities Output Leader Participants 2-2-1 List of the selected equipment ･RGD, maintenance ･Maintenance staff Selection of equipment ･Hospitals, maintenance ･Consultant 2-2-2 Basic management manuals by ･RGD, maintenance ･Maintenance staff Consultations for the preparation of basic type of equipment ･Hospitals, maintenance ･Consultant management manuals (A4sheet each) ･Supplier, distributors 2-2-3 Basic cleaning manuals by ･RGD, maintenance ･Maintenance staff Consultations for the preparation of basic type of equipment ･Hospitals, maintenance ･Consultant cleaning manuals (A4 sheet each) ･Supplier, distributors 2-2-4 Basic troubleshooting manuals ･RGD, maintenance ･Maintenance staff Consultations for the preparation of basic by type of equipment ･Hospitals, maintenance ･Consultant troubleshooting manuals (2-3 A4 sheets each) ･Supplier, distributors
･Activity Plan 2-3: Establishment of the flow of command up to repair Activities Output Leader Participants 2-3-1 Chain of command chart ･RGD, maintenance ･Maintenance staff Consultations concerning the flow of chains ･Hospitals, maintenance ･Consultant of command
[Example] Department in charge
Communications Repair by MU
Maintenance Unit Troubleshooting Contracting-out of repair work by MU Repair by distributor (MU) Bills for repair & parts (Approval by Director) (Payment)
Budget･ Accounting MU
･Activity Plan 2-4: Establishment of the flow of the procedures for purchase of repair parts, consumables and reagents Activities Output Leader Participants 2-4-1 Flow chart of purchase ･RGD, supply dept. ･Staff of budget･accounting Consultations for the establishment of the procedures ･Hospitals, supply dept. and supply dept. flow of purchase procedures ･Consultant
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[Example]
Departments in charge
(Communications)
Delivery of Goods to Distribute to dept. Supply of Goods Place order Supply dept.
(Bill) (Approved by the (Payment) Accountant Director)
･Activity Plan 2-5: Establishment of the flow of budget compilation for purchase expenses Activities Output Leader Participants 2-5-1 Flow chart for the drawing up ･RGD, accountant ･MOH, Planning dept. Consultations concerning the flow of chains budget for purchase of goods ･Hospitals, accountant ･Staff of Accounting dept. of command ･Staff of Supply dept. ･Consultant
[Example]
Departments in charge
(Communications)
Supply dept. Place order (Bill) Accountant
(Payment) (Approval by the Director)
･Assorting equipment ･Grasping the purchase frequency by type of equipment
･Examination of timing of budget compilation and filling of applications
(4) Schedule for the Implementation of each Activity Plan For the Soft Component Program the consultant will assign one engineer, who will be dispatched to the project sites in two separate stages as described in the table below. The work schedule of the engineer will follow the general work standard in Suriname; six hours a day, five days a week.
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Work schedule of the Soft Component Program
Detailed Design Stage Procurement and Installation Stage (Tendering) No. of Activity Plan: 1-1-1 No. of Activity Plan: 2-2-2 Consultations for the organization of the POU. Preparation of basic management manuals.
No. of Activity Plan: 2-1-1 No. of Activity Plan: 2-2-2 Summarizing of previous equipment data as prescribed by hospitals Preparation of basic cleaning manuals. and / or the MOH. No. of Activity Plan: 2-2-2 No. of Activity Plan: 2-2-1 Preparation of basic troubleshooting manuals. Selection of equipment for training sessions concerning the maintenance.
No. of Activity Plan: 2-3-1 Consultations concerning the flow of chains of command up to repair.
No. of Activity Plan: 2-4-1 Consultations for the establishment of the flow of purchase procedures.
No. of Activity Plan: 2-5-1 Consultations concerning the flow of chains of command
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